As discussed throughout this guide, teams might want to consider starting small and scaling up quickly by using rapid cycles of action-oriented learning. A great way to do this is by using the Plan-Do-Study-Act (PDSA) model.

Under PDSA, team members start by planning (plan) the intervention and then testing (do) it. In the next step, team members observe the test firsthand (study), paying close attention to competing demands and physical space. They listen to individuals involved in the test to hear what worked and what did not. They ask for alternative ideas and discuss them on the spot. The idea is to understand what could or should be done differently from how the team originally planned it. Whoever observes and studies the test records the lessons learned and suggested alternatives. These lessons and alternatives are then shared at the next team meeting. In the last step, the team revises the plan and tries it again (act).

Table 8.1 highlights the advantages of PDSA as well as principles for doing it well.

Table 8.1: Advantages of Plan-Do-Study-Act and Principles for Success

Advantages of PDSA

Allows “failures” to come to light without undermining performance and momentum.

Identifies areas of resistance that might undermine dissemination to other units.

Allows costs and side effects of the change to be assessed.

Increases certainty that change will result in improvement.

Allows detailed documentation of improvement.

Principles for Success

Start new changes on the smallest possible scale (e.g., one patient, one nurse, one doctor).

Run just as many PDSA cycles as necessary to gain confidence in a change.

Spread each change incrementally to more patients, then more nurses, then doctors, and finally to units.

Balance changes within the overall system to ensure other processes are not adversely stressed.

Pay special attention to preserving productivity and workflow.

Maintain and Spread the Gains

After successfully addressing the failure modes and putting in place an effective VTE prevention protocol, it is important to avoid assuming that the new process is “fixed” in perpetuity. Instead, keep monitoring the process.

Although implementation teams may be able to reduce the intensity of the process monitoring over time, some ongoing assessment of how the process is functioning is necessary. In addition, new findings from research publications, new therapies, and new patient situations arise frequently and may require revisiting the process or intervention. It is helpful if the team remains responsible for monitoring these issues, updating tools and processes, and revising the intensity of scrutiny based on the stability of the metrics. Ongoing measure-vention and intermittent audit and feedback reinforce best practices and avoid lags in performance.

Creating breakthrough levels of improvement is hard work, but it can also be exciting and rewarding. Indeed, the improvement in the venous thromboembolism (VTE) prevention process a team engineers can serve as a model for other areas in the organization. Ideally, the implementation success will spread as others learn from the experience, customize it to their own environment, and implement that version at a rapid pace.

An implementation project is generally considered ready for spread when:

There is evidence of improvement.

There is a model for the improvement that others in the organization can use (e.g., implementing on other units or in other hospitals within the health system).

There is strong support from senior leadership to spread the intervention.

Once these three goals have been achieved, the VTE improvement team may want to consider setting forth a plan for spreading the results. The plan should consider the following:

Which patient population to spread to next?

Which specific improvements to spread (i.e., not all may be appropriate for all populations)?

What modifications to interventions might be needed as the locations and population of patients change?

What timeframe is most appropriate?

What are the specific goals or targets for improvement?

Dissemination can be accelerated by adaption of clinical decision support and risk assessment tools in CPOE, by use of measure-vention reports, and by collaborative communities sharing examples of tools and resources. A spread plan should build on the organization’s existing approach to spread and rollout. It often helps for the team to work with a senior executive sponsor when developing the spread plan. Lastly, when executing the spread plan, be sure to measure performance and obtain feedback on the spread plan in order to improve upon the plan for the next idea.

Internet Citation: Chapter 8. Continue To Improve, Hold the Gains, and Spread the Results. Content last reviewed May 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/vtguide/vtguide8.html